Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit http://skinhelpdesk.com


Role of Hyaluronic Acid Treatment in the Prevention Keloid Scarring

Hyaluronic acid as a volume enhancer is an important tool in any dermatologist’s armamentarium. This interesting in vitro study demonstrated that HA has the potential to normalize some of the characteristic features of keloid fibroblasts such as hyperproliferation activity, growth factor production, and extracellular matrix deposition depending on the specific genotype of the keloid fibroblast cell line. Administration of high molecular weight HA is able to reverse keloid deficiencies such as hyperproliferation and aberrant ECM deposition to a more normal phenotype. Though it is still early days as the lab results do not always translate to clinical improvement, we may soon be injecting hyalunoric acid fillers into keloids instead of steroids.


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How Chlorophyll Cuts Acne

Acne is a common teenage problem that leads to severe psychological morbidity. Isotretinoin is an effective treatment but has several serious side-effects making it a final resort in recalcitrant cases. Several anecdotal remedies exist with many websites claiming successful magic-bullets to lure gullible teenage girls to shell out their pocket money.
Image Credit Meghan @ Flikr (Image altered and text added)
Photodynamic Therapy (PDT) is another treatment modality that makes use of photosensitizers such as 5-Aminolevulinic acid (ALA) and Methyl Aminolevulinate (MAL). These chemicals get converted to porphyrin that can release reactive oxygen species on exposure to certain wavelengths of light. However, they can remain on the skin for a prolonged period leading to photosensitivity and is not suitable for dark skinned patients. The quest for a better photosensitizer has been a priority for quite some time.


A recent study published in JAAD* proposes Chlorophyll-a as the superior photosensitizer that we were waiting for. Chlorophyll-a is apparently much safer that ALA and MAL and has the following advantages:

Chlorophyll-a has intrinsic photosensitizer characteristics and does not need prior activation. Hence, the onset of action is fast.
Chlorophyll-a undergoes spontaneous permanent degradation with no risk of prolonged photosensitivity.
Chlorophyll-a is cheaper than ALA and MAL

Please share/like below to read the fourth advantage:

 The histological changes following PDT showed a sustained decrease in pilosebaceous units. Hence Chlorophyll-a PDT may be as sustainable as isotretinoin in preventing recurrence.  The combination of blue and red lights are used for activation. The study shows good promise for Chlorophyll-a PDT to emerge as a sustainable and effective treatment for recalcitrant acne.

Reference:


*Byong Han Song, Dong Hun Lee, Byung Chul Kim, Sang Hyeon Ku, Eun Joo Park, In Ho Kwon, Kwang Ho Kim, Kwang Joong Kim, Photodynamic therapy using chlorophyll-a in the treatment of acne vulgaris: A randomized, single-blind, split-face study, Journal of the American Academy of Dermatology, Volume 71, Issue 4, October 2014, Pages 764-771, ISSN 0190-9622.
Keywords: acne vulgaris; chlorophyll-a; light-emitting diode; photodynamic therapy; photosensitizer; treatment

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Cosmetic Ingredients and Topical Steroid Abuse

This week I will be introducing few internet resources related to cosmetic ingredients and topical steroid abuse.

Image credit Cosmetic @ Wikipedia (Image altered and text added)

Links to all the resources are available below this post. As I have mentioned in my ten point rule, it is difficult to believe the information provided by cosmetic companies as validated research. Most cosmetic publications slump to marketing materials and most blogs in this domain are nothing but paid advertisements. Where can you find reliable scientific information on cosmetic ingredients and their potential good or bad effects?

I found John’s blog (1) on another platform while searching for skincare information. He has moved to his own blog afterwards called Triple Helixian (1). He has created evaluation rubrics for commonly used product categories such as sunscreens and cleansers and computes an ‘Alpha Score’ for products based on ingredients and packaging. This blog is an excellent resource for those looking for unbiased scientific information on cosmetic ingredients. John, if you see this, you are welcome to join our facebook group DsB and enlighten us with your knowledge through active discussions.

IADVL and many members of DsB are active proponents of the Anti-steroid abuse campaign. I am sure initiatives such as IADVL Task Force Against Topical Steroid Abuse (ITATSA) by Dr +KOUSHIK LAHIRI  would be helpful in educating patients on the perils of steroid abuse. Informed patients may be more capable of helping the campaign than journalists. Leslie is an atopic who was treated with topical and systemic steroids for symptomatic control, who later developed steroid dependence. He has started a blog called Say No To Topical Steroids (2) to raise awareness about topical steroid dependence and withdrawal symptoms. Though I doubt whether what he went through can be called a ‘steroid abuse’, It is an important eye-opener for all of us. Leslie has a huge collection of resources on topical steroid abuse. Best of luck with Leslie’s campaign though I do not endorse his tag line. I would prefer it to be ‘Say No To Topical Steroid Abuse’.


Weekly Roundup: Here is a study that demonstrates the efficacy of a vaccine suitable for use in trials against different EBV-positive cancers.(3) This study found a correlation between childhood eczema and concentrations of airborne mold in homes with water damage. (4) This may be a reason for the higher incidence of atopic dermatitis in the perpetually air-conditioned middle eastern households.

To all my friends practicing in Middle East: Do you think atopic dermatitis is more common there?

Please support/like below to see the references to the blogs and articles.


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Time to respect your patient privacy

In a small town called payyanur in Kerala, INDIA, three doctors were suspended for allegedly sharing a labour room video of triplets being delivered by C-section on social media. The powerful local media rebuked the medical community for their irresponsible behaviour.

Is taking clinical photos on your mobile second nature for you?   Do you share them on Facebook? 

Photo credit: Jay Wennington @ unsplash.com
Think again. In this fast growing digital world, it is time to consider the repercussions. This is not a review of the privacy concerns. Please refer to Kunde et.al (below) for a short and sweet review on ethical and medico-legal considerations of digital photography in dermatology. This is about a solution, though little cumbersome and incomplete.

Dermatology is a speciality that depends on visual cues. Photography can even be considered therapeutic in dermatology, since it is an important part of disease monitoring. Social media like facebook is an important and popular platform for crowdsourcing diagnosis. This is especially important for those practicing in resource deprived areas. How can this be achieved without compromising patient privacy?

I have developed a tool for visual diagnostic information encoding. The tool called LesionMapper(TM) captures information such as location, distribution, progression and severity using pre-defined representative lesion images and icons. It also provides the capability to create lesion icons from existing clinical images. Without further ado here is the link to LesionMapper(TM): http://skinhelpdesk.com/lesionmap.html


Lesion Canvas for LesionMapper(TM)

The instructions tab has details on how to use it. Below I have added basic steps to add a lesion from your photograph. Please note that using LesionMapper(TM) does not guarantee anonymity. It is your responsibility to ensure that you have obtained the necessary consent. If the preset images and icons are insufficient, you can crop the lesion from the clinical image  itself as below.

  1. Go to http://skinhelpdesk.com/lesionmap.html
  2. Click on Upload Image 1 (Blue Button)
  3. Upload your image. Select only the lesion and follow instructions. (In the new window)
  4. Click on Upload 1 (White button). Image will be added to canvas. If not press the button again.
  5. Drag the image to the area of involvement. You can resize the image if needed.
  6. Click on the Download button (A small button right below the image). You can also save it on the site. You will be provided with an ID that can be used to render the image by clicking on Load.
Please share below to see the reference to medico-legal considerations in dermatology photography.

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Oral tranexamic acid for the treatment of melasma

My Friend Mr +Devdas Pai  asked for a review of this article [1] (Link to full text below) and our experience on oral tranexamic acid for the treatment of Melasma.

English: Melasma on the face
Melasma on the face (Photo credit: Wikipedia)
I don’t have personal experience using oral tranexamic acid, an antifibrinolytic hemostatic agent with alleged activity as a melanin synthesis inhibitor. Do I think whether this study provides a proof for this activity that was suggested way back in 1979? Not really!

We discussed the methodological challenges in cosmetic dermatology research before and I don’t believe that an RCT should be the gold standard in cosmetic dermatology. But unfortunately, if you set out to prove something in cosmetic dermatology, you invariably can if you use subjective assessments without blinding! When your eyes are not blinded, the random number generator does not do justice in allocation either with a substantial difference in epidermal type of melasma in both groups, enough in my opinion for the demonstrated effect size.

Digital photographs are your best weapon to prove your point. The photograph in the article will probably give you hopes of the miraculous melasma eraser. But you can easily see the difference in white balance between the before and after pictures by looking at the shadow below the nose.

Recurrence is the biggest limitation in melasma management. A statistical quirk has been inappropriately exploited to allude to a sustainable solution without real evidence. The study provides ample proof for the authors conviction in the agent, but not for its actual effect on melasma. Go ahead and try it if you are adventurous. I shall stick to my trusted treatment; PhotoShop :)

Please support below to see the full text of the article.

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Allured to Lignin Peroxidase

In this article I have reviewed lignin peroxidase (LIP) as a skin tone enhancing cosmetic. This is not a paid review.

Various types of cosmetic concealer.
Various types of cosmetic concealer. (Photo credit: Wikipedia)
Is it fair enough to say that 1.3 billion people in Indian sub-continent and many more in the far east have found the panacea for FAIR beautiful skin. Though only few of them will be able to afford LIP and the company aptly follows my time machine rules, I must say that I find the theory behind  LIP (distributed under a popular trade mark name) enticing.

The theory sans all the hype is simple: An isoenzyme of LIP (H1 or modified H2 to be exact) can oxidize melanin in the presence of an electron acceptor in acidic pH. So it is not, 'yet another tyrosinase inhibitor' and theoretically aid removal of already formed melanin. European CRO that reported their "Asian" trials  on company inscribed reports was hardly convincing  with their hanging "significant" improvement in 8 days.

The preparation transiently brings the cutaneous pH to acidic levels for LIP to have its effect. Once the pH returns to normal, LIP disintegrates and vanishes ensuring high safety profile. Since hypopigmenting properties of LIP secreting fungi are long known, this melanin zapper could be a reasonably good addition to any pigmentation treatment (if it were cheaper). It must be noted though that the patent application was filed in 2003 and the idea of a fungal derived fairness agent is not exactly theirs.

I have added LIP to the 'elimination' arm of Pigment Map Project. Do you agree with this placement?

I give 3 peels to the concept (The highest I have ever given to a cosmetic, despite 'sold only to aesthetic physician or spa' marketing gimmick ). Do give your rating using the widget below.

GulfDoctor.net peel rating
What is peel score?

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Finn CLAIMS IQ

English: 2+ patch test reaction
2+ patch test reaction (Photo credit: Wikipedia)
Back in the dark ages, when I was doing my PG in Manipal, we had something that very few dermatology departments had at that time. The IQ Chamber for applying the European Standard Series on your back to find out what you are allergic to, aptly called a patch test. We published the largest Indian collection (then) of footwear dermatitis results.  ***self promotion :)

Much water has flown down the River Netravati, and patch test has become a common part of dermatology practice. Though we made our own Indian Standard Series, the chambers had to come all the way from Sweeden and USA, reminding us of our inadequacies. But a CRO from Mumbai - CLAIMS claims that the plastic, our own Reliance makes, is as good as their Swedish cousin.

Though this seems relatively straight forward hypothesis to test, CLAIMS has done a remarkably good job in the study design, execution and statistical analysis. Kudos to the CLAIMS team for conducting and publishing this study, though I personally feel the article published in IJDVL (1) could have been improved. Besides a disclaimer that Chamber X is going to be (is being) used/marketed by CLAIMS Pvt. Ltd as "Claims Chambers" would have been appropriate.

Please rate this article:

Ref:

1. Sajun Merchant SZ, Vaidya AD, Salvi A, Joshi RS, Mohile RB. A new occlusive patch test system comparable to IQ and Finn chambers. Indian J Dermatol Venereol Leprol [serial online] 2014 [cited 2014 Aug 19];80:291-5. Available from: http://www.ijdvl.com/text.asp?2014/80/4/291/136830

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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.

Address

Bell Raj Eapen
Hamilton, ON
Canada
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